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Network Prior Auth & Referral Specialist

Company: St. Luke's University Health Network
Location: Allentown
Posted on: May 25, 2023

Job Description:

St. Luke's is proud of the skills, experience and compassion of its employees. The employees of St. Luke's are our most valuable asset! Individually and together, our employees are dedicated to satisfying the mission of our organization which is an unwavering commitment to excellence as we care for the sick and injured; educate physicians, nurses and other health care providers; and improve access to care in the communities we serve, regardless of a patient's ability to pay for health care.The Network Prior Authorization and Referral Specialist is responsible for the coordination of prior-authorizations and referral process for patients being referred for specialty care, diagnostic procedures, and surgery. Performs scheduling, insurance verification, obtaining pre-authorizations, and referrals. Ensures notification of reimbursement to physicians, nurses, financial clearance staff, and patients prior to services being rendered.

  • Obtains prior-authorizations and referrals from insurance companies prior to procedure or testing utilizing online websites or via telephone
  • Monitors and updates current Orders and Tasks; managing Orders through Allscripts and Epic to provide up to date and accurate information
  • Provides insurance company with clinical information necessary to secure prior-authorization or referral
  • Works in alignment with Central Scheduling and Pre Encounter Departments.
  • Obtains necessary electronic referrals needed from scheduled specialty appointments
  • Obtains and/or reviews patient insurance information and eligibility verification to obtain prior-authorizations for diagnostic testing, medications, injections, DME, and surgeries.
  • Request retro-authorizations when needed.
  • Communicates with patient regarding the visit and prior-authorization process.
  • Provides support to physician group and community practices with utilization issues.
  • Works with community practices to obtain prior-authorizations.
  • Communicates with practices when prior-authorization is unable to be obtained and requires peer-to-peer and/or different study.
  • Documents in all systems prior-authorizations to ensure proper reimbursement
  • Verifies and completes patient eligibility, coverage verification, and benefit investigation --for the procedure using an online application or by telephone.-- If the patient is not eligible on date of service or procedure is not covered, this information is relayed to the physician and the patient
  • Responds to written and telephone inquiries from patients, insurance carriers and facilities regarding planned services.
  • Takes an active role in facilitation team approach to functions within the department:
  • Attends departmental meetings
  • Actively participates as a team member in resolution of problems as they are identified
  • Analyzes current procedures, bringing suggestions for improvement to the attention
  • Contacts Central Scheduling, Patient Access Department, and patient, to relay precertification information
  • Notify ordering physician of any prior auth denials and peer to peers to be scheduled
  • Review and validate the accuracy of therapy plan/treatment plans ordered by reviewing H&P and medical records to ensure medication ordered is the same as what is being prior authorized
  • Validate medication ordered is on the payer preferred drug list
  • Identify buy and bill authorizations vs. delivery and document account accordingly
  • Review and follow up on authorization denials and claim denialsPHYSICAL AND SENSORY REQUIREMENTS:
    Sitting for up to 8 hours per day, 3 hours at a time.-- Consistent use of hands and fingers for typing, telephones, data entry, etc.---- Occasional twisting and turning.-- Uses upper extremities to lift and carry up to 15 pounds.---- Stoops, bends, and reaches above shoulder level to retrieve files.-- Hearing as it relates to normal conversation.-- Seeing as it relates to general vision.-- Visual monotony when reading reports and reviewing computer screen.
    High School diploma or equivalent required.
    One to two years of experience in medical billing office, medical setting or insurance company.-- Working knowledge of medical business office procedures and basic accounting and detailed understanding of ICD-10 and CPT codes. Strong knowledge of regulatory standards and compliance requirements.---- Previous pre-certification experience helpful.-- Previous Medical Assistant experience highly desirable.
    Please complete your application using your full legal name and--current home address. --Be sure to--include--employment history for--the past seven (7) years, including your present employer.-- Additionally, you are--encouraged to upload a current resume, including all work history, education, and/or certifications and--licenses, if applicable. --It is highly recommended that you create a profile at the conclusion of submitting your first application. --Thank you for your interest in St. Luke's!!

Keywords: St. Luke's University Health Network, Allentown , Network Prior Auth & Referral Specialist, Other , Allentown, Pennsylvania

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